by George W. Albee
When he was Director of the National Institute of Mental Health,
Lewis Judd
MD proclaimed the 1990’s to be the "Decade of the Brain" during
which
research would locate all the causes of mental disorders in the
brain (it didn’t).
The recently-resigned Director of the National Institute of Mental
Health
Steve Hyman MD (now Provost at Harvard) says: "These are real illnesses
of a
real organ, the brain, just like coronary artery disease in a disease
of a real
organ, the heart".
E. Fuller Torrey MD, psychiatrist and chief guru of the National
Alliance for
the Mentally Ill, argues that people with severe mental disorders
have
"neurobiological disorders of their brains that affect their thinking
and moods
and that can be measured by changes in both brain structure and
function". Torrey is also a leading advocate for involuntary drug treatment
of the emotionally disturbed.
Recently an important new mental disorder, Anosognosia (translation: lack of awareness of illness), has been announced by the American Psychiatric Association (see Professional News, 2001, 36, 17, p. 13.). While this phenomenon was long known by the psychological term denial, it is now said to be a result of a brain defect, according to a recent article in Psychiatric News. (September 7, 2001).
Anosognosia is commonly seen in persons (diagnosed by psychiatrists)
with serious mental illnesses like schizophrenia. Many diagnosed schizophrenics
"do not believe they are ill despite evidence to the contrary" (p.1). Some
"have a compulsion to prove to others that they are not ill". (p.1). These
people are now said to be suffering from the brain defect that causes anosognosia.
This means, of course, that they have two mental illnesses requiring treatment
(schizophrenia and anosognosia). The treatment
may have to be involuntary (forced) as they deny being ill at all.
(Unclear is whether also denying that one has a brain defect causing anosognosia
is itself an illness caused by still another brain defect).
There are several puzzling questions as yet unanswered. Examples:
1. For many years homosexuality was included in the DSM as a mental
illness.
A great many people, straights, gays, lesbians, bisexuals, argued
that it was
not a "mental illness". Were all of them suffering from anosognosia?
Did they
have a brain defect? Since 1972, when homosexuality was removed
from the
DSM, it no longer is considered a mental illness. Should there be
a diagnostic
category for all those psychiatrists who for many years were wrong
when they
insisted that homosexuality was a mental illness when it is not?
A puzzle.
2. Some current mental illnesses were not considered mental illnesses
until
recently. Adolescent rebellion, arithmetic learning problems, childhood
hyperactivity and attention deficit were not mental illnesses until they
were put in DSM III & IV. If children were exhibiting these behaviors
at the time the behaviors were first called mental illnesses could they
argue pre-existing non-illnesses? Does the brain defect occur only after
the illness is named?
3. For many years a very large number of people suffered with a neurosis.
Freud was especially interested in the neuroses and their cure through
psychoanalysis. Popular neuroses included neurasthenia, psychasthenia,
hysteria, hypochondriasis, and multiple personality. But in DSMIV
these
long-used diagnoses were stricken from the diagnostic system. Unlike
homosexuality, which still exists but is not a mental illness, the neuroses
apparently no longer exist. Were all those millions of neurotics suffering
from non-existent disorders? If they agreed that they were neurotic, but
were not, were they suffering from a still-unnamed disorder that we might
call pseudognosia? Is it caused by a brain defect? Is Woody Allen really
a non-neurotic?
4. American and British psychiatrists vary consistently and significantly
in the
frequency with which they label people "schizophrenic". American
psychiatrists
use this diagnostic label far more often than their British colleagues.
To check
the possibility that Americans might be more prone to this disorder
a clever
experiment sent a group of American psychiatrists to London to see
incoming
cases to a mental hospital for diagnosis, and brought a group of
British
psychiatrists to Brooklyn to see an incoming set of Americans requiring
diagnosis. Sure enough, the American psychiatrists, true to form,
saw larger
numbers of Brits in London as schizophrenic, and the British psychiatrists
saw
fewer Americans with this diagnosis. Now the question is: If a British
tourist
acting strangely is taken to Belleview Hospital in New York and
labeled
schizophrenic can he/she argue that his/her psychiatrist back home
disagrees, and claim not to be schizophrenic? Does he/she have a
brain
disease, but only in America? Similarly, if an American labeled
schizophrenic
at home, on holiday in England, declares "I am not schizophrenic"
is this
declaration valid, or a case of extraterritorial Anosognosia?
5. It is not uncommon for distinguished psychiatrists to disagree
on a diagnosis
of schizophrenia, and even for groups of psychiatrists testifying
for the
prosecution and for the plaintiff to come to opposing positions.
In the trial of the
young man who shot President Reagan (to try to impress actress Jody
Foster)
he was seen as sane by psychiatrists for the government and as insane
by
psychiatrists representing the family. The jury believed the latter
group and
ruled him "Not Guilty by Reason of Insanity ". In an ironic twist
he is
incarcerated in St. Elizabeth’s Hospital in Washington, D.C. in
the care of
government psychiatrists who found him sane! Who has the Anosognosia
here?
6. Recently it has been asserted that relatives of schizophrenics
may show
"early signs" of the condition. They are alleged to be "genetically
vulnerable".
Now, it is suggested, these people might benefit from prophylactic
drug treatment, thereby preventing the debilitating consequences
of later
full-blown development of the condition. The problem arises: If
a relative
does carry a diagnosis of incipient schizophrenia, and denies that
they are at
risk, can they be said to be suffering from anosognosia? If they
successfully
resist this prophylactic treatment for many years, even a lifetime,
and appear
normal throughout does this require correction of an earlier diagnosis
of
anosognosia? Can they sue?
7. Finally, there is a mammoth problem. Mary Boyle, a distinguished
British
psychologist, has written a brilliant, carefully documented account
of the
history of "schizophrenia". She details the confusion, the inconsistency,
the
lack of reliability, of the concept and concludes that in all probability
there is
no such disease. (It should not be necessary to say that some people
do have
psychotic symptoms). But the new label Anosognosia supposedly is
common in
schizophrenics (who cannot be schizophrenic if the condition does
not exist).
If schizophrenia does not exist then those who deny that they are
schizophrenic are correct and cannot have a brain defect that causes
the
denial!
This bizarre situation suggests that brain defects should be identified
only by
direct observation (by neurologists preferably) rather than inferred
from
unreliable observations. One of the great advancements in human
knowledge and thought has come from the rise of science. Science has many
characteristics including the reluctance to accept any finding as absolute.
Hypotheses are accepted or
rejected with varying degrees of confidence, never with certainty.
And
scientists are always ready to examine new findings with appropriate
skepticism. They repeat experiments or design new ones in a serious
attempt
to find errors. Unfortunately, in psychiatry, much that passes as
research is
financed by the pharmaceutical corporate giants. They pay for the
research. They pay the referees who judge the research. They underwrite
the cost of the conferences where results are announced and the cost of
publishing the psychiatric journals where they are published. The usual
freedoms of scientific inquire are missing. Anosognosia is just the latest
example of a concept that has not received serious scientific study. But
it will be effective in selling more "drugs for the mind".
[Submitted to NY Times OpEd Page, December 22, 2002]